To have your child or grandchild delivered without the damaging effects
of Immediate Cord Clamping, you need to discuss this option with your
obstetrician. You should provide your physician with an informed
consent form (as shown below) which should be signed by the parent and
the physician. To obtain a printed copy of this form click on
either of these two buttons:

SAMPLE FORM

Informed Consent for Clamping the
Umbilical Cord

Immediately after a baby is born, the
cord and placenta continue to supply it with food and oxygen; blood
from the placenta flows into the child. This “placental
transfusion” establishes the lung circulation, essential for normal
breathing, and ensures good blood flow to all other vital organs,
including the brain. After the child is breathing well, and after a
sufficient amount of placental blood has been transferred, the
umbilical cord blood vessels clamp themselves – they close
naturally.

If the cord is clamped immediately,
the oxygen supply is cut off, and a very large amount of the child’s
blood may be clamped in the placenta. This may result in the baby
being very pale and weak; the lungs and all other vital organs may
not function well due to defective blood flow. In extreme cases,
multiple organ damage from poor blood flow may occur, including
brain damage. The child may become anemic; infant anemia is
associated with mental retardation in childhood.

If cord clamping is delayed until the
child is breathing and pink, and until all pulsations in the cord
have ceased, and especially if clamping is delayed until the
placenta has delivered, the child will have received the best
possible amount of blood for a healthy life. Infant anemia is
prevented; mental retardation is prevented.

Delayed clamping is very important
for any child delivered by cesarean section or for any child born
“depressed.” Resuscitation requires transfer of a large amount of
oxygenated blood from the placenta. Oxygen in the lungs will not
revive a child if no blood is flowing through the lungs. The
depressed child needs a placental transfusion.

Instructions regarding treatment
of the umbilical cord:

After the birth of my baby, the
umbilical cord shall not be clamped or cut until the baby is
breathing and pink, and until all pulsation in the cord has ceased,
and until the placenta has delivered.

Signed:
_______________________________________________ parent(s)

Signed: _____________________ MD.
______________________ RN

Page 2.

Explanation and Guidelines for the
Physician

There are two (rare) indications for
immediate cord clamping (ICC):

1. When a
short cord ruptures spontaneously and bleeds during birth.

2.
When a c-section for anterior
placenta previa involves incising or damaging the placenta.

In these cases, cord blood should be
stripped into the child, and the placenta should be preserved; any
blood left in it may be used for auto transfusion.

Physicians should be familiar with
management of a nuchal cord using the “somersault maneuver.” Never
clamp a nuchal cord. See “The Cerebral Palsy Baby” (CP) at

The newborn should always be
positioned at or below the placental level, even at c-section, if
the cord is long enough to permit this.

Maternal blood loss is decreased and
placental transfusion is hastened with use of intravenous oxytocin
during the third stage.

Neonatal depression

If a child is born very depressed,
(limp, pallid and unresponsive) with a pulsating cord, the placenta
is the only organ sustaining life; it should not be amputated.
There should be no hurry to ventilate. The child is in a state of
generalized vasoconstriction; it may take a few minutes of placental
transfusion to reverse this, to establish pulmonary circulation and
to restore breathing reflexes. Lower the child well below the
placenta.

If the heart rate stays above 100 bpm
for a minute or two, a cold sponge placed on the back or chest
momentarily will usually start respiration; if this does not,
bag-mask the child. A cord pulse rate >100 bpm indicates an
adequately oxygenated child. Even with a very depressed child at
birth, resuscitation using placental oxygenation and placental
transfusion will usually result in a five-minute Apgar of nine or
ten. If the heart rate is below 100 bpm, “milk” cord blood into the
child.

Standard of Care:
Standard care (ICC with instant resuscitation and ventilation) has
not reduced the incidence of CP or litigation. Ischemia is
visualized on MRI in the CP child. ICC is a proven cause of infant
anemia, and the ICC epidemic of standard care
coincides with the current autism epidemic. Physician, heal thyself!

Physiology has never been shown to
harm a child. The physiology of natural resuscitation is discussed
at the web site:
www.cordclamp.com